Commitment and Care: The benefits of a healthy workplace for nurses, their patients and the system A Policy Synthesis
Commitment and Care: The benefits of a healthy workplace for nurses, their patients and the system Andrea Baumann 1 RN, PhD Linda O Brien-Pallas 2 RN, PhD Marjorie Armstrong-Stassen 3 PhD Jennifer Blythe 4 PhD Ren e Bourbonnais 5 DSc Sheila Cameron 6 RN, EdD Diane Irvine Doran 7 RN, PhD Michael Kerr 8 PhD Linda McGillis Hall 9 RN, PhD Michel V zina 10 MD, MPH, FRCP Michelle Butt 11 RN, MSc Leila Ryan 12 MA, PhD 1 Associate Dean of Health Sciences (Nursing), Professor & Co-Director, Nursing Effectiveness, Utilization and Outcomes Research Unit, School of Nursing, McMaster University 2 CHSRF/CIHR National Chair Nursing Human Resources, Professor, Faculty of Nursing & Co-Director, Nursing Effectiveness, Utilization and Outcomes Research Unit, University of Toronto 3 Professor, Management and Labour Studies, Faculty of Business Administration, University of Windsor 4 Scientific Officer, Nursing Effectiveness Utilization and Outcomes Research Unit & Assistant Professor, School of Nursing, McMaster University 5 Chercheure, Facult de M decine, D partement de R adaptation, Universit Laval 6 Executive Dean, College of Graduate Studies and Research & Professor, University of Windsor 7 Associate Professor, Faculty of Nursing, University of Toronto 8 Scientist, Workplace Studies, Institute for Work and Health & Associate Professor, Department of Public Health Sciences, Faculty of Medicine and School of Graduate Studies, University of Toronto 9 Assistant Professor, Faculty of Nursing, University of Toronto 10 Directeur, Direction de la Sant Publique, R gie R gionale de la Sant et des Services Sociaux du Quebec (1999-2000); Conseiller M dical en Sant au Travail l Institut National de Sant Publique du Qu bec (2000-2001). 11 Senior Research Associate, Nursing Effectiveness, Utilization and Outcomes Research Unit, School of Nursing, McMaster University 12 Assistant Clinical Professor, School of Nursing, McMaster University Acknowledgments This research was funded by the Canadian Health Services Research Foundation and The Change Foundation. Contributing partners included Health Canada, the Canadian Nurses Association, the Victorian Order of Nurses, the Canadian Council on Health Services Accreditation, the Calgary Regional Health Authority and St. Michael s Hospital in Toronto. The Nursing Effectiveness, Utilization and Outcomes Research Unit, funded by the Ontario Ministry of Health and Long-Term Care, provided additional support. The research team would like to thank the people who participated in the focus groups and interviews across Canada. We would like to acknowledge the help of Melanie Lavoie-Tremblay who carried out interviews in Quebec. As well we would like to thank the staff of the Nursing Effectiveness, Utilization and Outcomes Research Unit at McMaster University and the University of Toronto, in particular Shirliana Bruce, Katie Wadey and Angela Thomas, who assisted with focus groups and interviews. We would like to thank Heather Spence Laschinger for her summary of the literature on job strain and organizational empowerment, and the individuals and organizations that contributed information and grey literature.
This report, including three appendices not published here, is available on the web at: www.chsrf.ca and www.changefoundation.ca c 2001 ISBN 0-9689154-1-8
Main Messages Canada s nursing shortage is at least in part due to a work environment that burns out the experienced and discourages new recruits. But that environment can be changed. The job satisfaction level of nursing staff has been shown to be a strong determinant of the overall satisfaction level of clients. Satisfaction improves with manageable workloads and when employers make it easier to balance work and home life. Nurses greatly stressed and vulnerable to injury have a higher absentee and disability rate than almost any other profession, which disrupts care, makes planning difficult and costs the healthcare system a great deal of money. Increased workloads improve short-term productivity but increase long-term costs, as nurse stress and illness may lead to poor judgment and low productivity that can hurt patients. Delegating more work to aides and unit clerks so nurses can concentrate on their patients reduces some of that stress. Nurses work best and have more loyalty to their employers when their expertise is respected, they have some control over their lives (such as the ability to set their own hours) and they are free to practice to the full scope of their education. Keeping staff is easier in a less-stressful, more supportive workplace, and good relations on the care-delivery team benefit patients and may even reduce death rates. Reducing staff turnover and letting nurses practice independently within a co-operative setting could do much to improve the work atmosphere. There are many other ideas in this report some based on experience, some drawn from research evidence that can help improve nurses working environment. Some are as simple as providing parking spaces close to the building for the safety of night workers; others, such as multi-year funding for the healthcare system, require co-operation on every level, from employers to the federal government.
Executive Summary The Canadian healthcare system is facing a nursing shortage that threatens patient care. Many nurses, physically and mentally exhausted, quit; employers can t fill those vacancies, while paradoxically other nurses can t find secure jobs with hours that suit them. Meanwhile, nursing schools can t keep up with the demand for new recruits. While caring for the sick and dying has always been demanding, many of the problems facing nurses today seem to arise from work environments that have grown increasingly difficult through the cutbacks and upheavals of the 1990s. This paper was commissioned to answer two questions: What is the impact of the working environment on the health of the nursing workforce (and hence, potentially, on patient outcomes)? What effective solutions could be implemented to improve the quality of the nursing work environment (and hence, potentially, patient outcomes)? Research has made it clear that problems with nurses work and work environments, including stress, heavy workloads, long hours, injury and poor relations with other professions can affect their physical and psychological health. Research across occupations has shown long periods of job strain affect personal relationships and increase sick time, turnover and inefficiency. To prepare this report, we did a wide-ranging survey of peer-reviewed research on nursing and work in general; read a vast array of other writing on the state of nursing; and interviewed or held focus groups with healthsystem managers, nurses, government employees, educators, representatives of nurses associations and unions. From these sources, we outlined the problems facing nurses and defined them as issues of work pressure, job security, workplace safety, support from managers and colleagues, control over practice, scheduling and through stronger leadership roles for nurses and rewards. There is no denying the seriousness of the challenges facing nursing, but we found many solid ideas for improving the situation. There are clear reasons why those running the healthcare system from the largest hospital to a small community clinic as well as the ministries who set their budgets and shape policy at the federal and provincial level, need to act. Organizations that do not create quality environments to attract new recruits and retain experienced nurses risk shortages that may endanger patients. What can be done? Nurses, like most people, need some basic predictability in their lives. That means they need to get back a sense of job security and feel that the risk of injury and workplace violence has been reduced. Longer budget cycles would help employers ensure that jobs won t disappear. Better equipment and more staff can help reduce the risk of injuries, which increases when there is no one to help turn a patient or when a nurse gets so busy and overextended that she pricks herself with a used needle. Studies show good relations among caregivers benefit patients, even to the point of reducing mortality. We believe that means
nurses need more support on the job, from managers who understand their work, respect their expertise and can offer a sense of security and community. It means rebuilding a team approach to nursing where the focus can be on the patient and not on inter-professional conflict. It means ensuring a manageable workload; it means offering educational and career opportunities and the time to pursue them. co-operation. If better patient outcomes are to be attained, governments, employers, educators and nurses must work together to create a healthy nursing work environment. One study found that nurses job satisfaction is the strongest determinant of clients overall satisfaction. Like most people, nurses work best when they have a sense of control over their jobs and their lives. That sense of control can be created by giving nurses more voice in patient-care planning, more voice in policy-making and more say over the way they work (such as being able to set their own hours or not making them work mandatory overtime). A demoralized worker is not a productive worker, and nurses have a sense they are not valued by the healthcare system for which they work so hard. Despite the increasing shift of care into the home and other non-hospital settings, community nurses are often paid less than their hospital counterparts. Some casual nurses have more say in their hours than fulltime employees. Money isn t everything, but it is an important measure of worth. Incremental pay increases recognizing expertise and experience, combined with more opportunities in management and a clearer voice in running the system, would improve the status of nurses in their own eyes and throughout the system. This summary outlines some ideas for improving working conditions in healthcare. There are many more in the report itself, ranging from finding more positions for nurse practitioners to including standards for healthy workplaces in hospital accreditation. Some are simple to act on locally; others will require
Final Report Why is Nurses Well-Being Important? 1 Commitment and Care Many trades and professions are suffering shortages and nursing is one of the most challenged. 1 The Canadian healthcare system is encountering a nursing shortage that threatens patient care. The symptoms of this quiet crisis 2 include difficulties in filling nursing vacancies, particularly in specialty areas, fewer people entering the profession, and more leaving for other careers. Nurses are also getting older the average age of the Canadian registered nurse rose from 41 in 1994 to 43 in 1999 3 and, since most nurses retire in their mid-fifties, a large cohort will be leaving the profession in the next 10 years. 4 Problems with nurses work and work environments have been discussed in research literature and among nurses and managers for many years. Stress caused by heavy workloads, long hours, low professional status, difficult relations in the workplace, difficulty in carrying out professional roles, and a variety of workplace hazards can affect physical and psychological health. When there were plenty of nurses available to care for patients, stress was less of an issue; today, organizations that do not create quality environments to attract new recruits and retain experienced nurses risk staff shortages that may endanger patients. Decision makers and other stakeholders in the healthcare system face the challenge of understanding this crisis and acting to resolve it. Although in many ways, the challenges nurses face in 2001 are similar to those encountered in the 1980s, changes in society, including the aging population, have made them more acute. While caring for the sick and dying is always demanding, healthcare restructuring intended to get organizations to do more with less meant fewer nurses care for more, and sicker, patients. Restructuring also restricted nurses employment choices, career mobility, and career plans. 4,5 More part-time and casual positions were created, chief nurse and head nurse positions were cut, and there was minimal investment in continuing education and professional development. Nor were changes restricted to hospitals. Greater demands were placed on nurses in the community and long-term care because technological advances enabled patients to move to these settings after shorter hospital stays....long periods of job strain affect personal relationships and increase sick time, conflict, job dissatisfaction, turnover and inefficiency. Research across occupations suggests that long periods of job strain affect personal relationships and increase sick time, conflict, job dissatisfaction, turnover and inefficiency. 6,7 Job strain exacerbates medical problems and increases the risk of musculoskeletal injury and accidents, burnout, illness, substance abuse and an increase in smoking. 6,8,9,10,11 Absenteeism among nurses rose steadily from 6.8 percent in 1986 to 8.5 percent of the nursing workforce in 1999 and has become a
major expense for individual institutions and the healthcare system. 12,13 High rates of longterm absenteeism for psychological reasons, 14 evidence of job dissatisfaction and high rates of musculoskeletal injury are cause for employer concern. Nurses are increasingly likely to begin work with a university degree and to have other career options if they fail to find nursing rewarding. Managers face the short-term problem of recruiting and retaining sufficient nurses to care for a growing patient population. In the long-term, they must create a sustainable workforce whose well-being supports optimum patient care. Scope of the Report This report, a synthesis of published research and experiential knowledge of nurses health and well-being in the workplace, answers two questions: Figure 1 What is the impact of the working environment on the health of the nursing workforce (and hence, potentially, on patient outcomes)? What effective solutions could be implemented to improve the quality of the nursing work environment (and hence, potentially, patient outcomes)? In the report, the term work environment includes the units in which nurses work, such as wards or programs as well as the organization (hospital or community) that employs them and, to some extent, the social context of government, profession, and public opinion. Health refers to overall well-being, not just whether someone is sick or healthy. The Approach Collecting the Data The multi-disciplinary research team combined its expertise in health human resources, restructuring, workplace operations, workload, coping, job satisfaction, skill mix, workplace injuries and psychological health to bring together and analyse the data on nurses worklife. The Quality of Nursing Worklife model 15 was used to guide this process. This model has been used extensively to organize research on nursing worklife and Figure 1 shows how it provides a framework for visualizing the forces inside and outside the workplace that influence the well-being of nurses and ultimately, their 2 Commitment and Care
3 Commitment and Care patients. Internal influences include administrative factors such as organizational policy, the ways in which policy is put into practice, the physical and social environment of the workplace and factors relevant to individual nurses. External factors include healthcare policy, the nursing labour market, and demands on the healthcare system. The report is based on three resources: a review of the published literature; an analysis of grey literature unpublished literature such as reports, working papers and manuscripts; and transcripts of focus groups and interviews. From the published literature, the team selected scientific studies providing generalizations about workplace characteristics and processes. No randomized controlled trials were located but a number of well-controlled correlation studies were found. The team also reviewed relevant descriptive studies and publications based on perceptions, political agendas and emerging trends which were essential for understanding the realities of the contemporary workplace. The grey literature provided an important source of information that was more up-to-date than peer-reviewed literature but too preliminary or specific to an organization to be published in a journal. (More information on the grey literature and a summary of focus-group participants and interview subjects, in English only, in Appendices C and E of Commitment and Care, available on the Canadian Health Services Research Foundation website at www.chsrf.ca or www.changefoundation.com). Team representatives held meetings, focus groups or telephone interviews throughout Canada with a range of people interested in nurses well-being, including administrators, representatives of unions and associations, educators and front-line nurses. They asked participants two questions What are the major issues that affect nurses well-being? What solutions are there to problems associated with these issues? and inquired about programs already in place. (Details of management and policy initiatives tried across the country are available in Appendices A and B of Commitment and Care, or at www.chsrf.ca or www.changefoundation.com). Assessing Nurses Work Environments Once the major issues in nursing workplaces were identified, the researchers needed to understand their relevance to nurses by relating them to the characteristics of healthy workplaces. Kristensen s model 16 for society, stress, and health is built on the demand/control or job strain model developed by Karasek and Theorell and their associates 17,18 and the effort-reward model developed by Siegrist and his colleagues, 19 as well as rigorous studies by other researchers. The model combines six dimensions of stressors that have been identified through research and relates them to both the individual and the social dimension. According to this model, the optimal work environment for social and psychological well-being includes: demands that fit the resources of the person; a high level of basic predictability; good social support; meaningful work; a high level of influence at work; and a balance between effort and rewards. The research team used this model to assess well-being in nursing workplaces because it was based on well-substantiated research evidence and provided a useful framework for discussing major issues that were identified in the literature and evidence from the field. The only change made to the model was to reorder the principles so that demands that fit the resources of the person had precedence, reflecting the importance that
The Nursing Work Environment: Principles, Issues and Solutions stakeholders attributed to workload. Table 1(below) illustrates how major issues relevant to nurses well-being identified in the analysis of literature, focus groups and interviews were categorized according to Kristensen s six principles. 16 Some issues relate to more than one principle but, for convenience, are ascribed to only one. Demands that fit the resources of the person Work pressures Issues: Many stakeholders consider that lack of fit between the work demanded of nurses and what nurses can reasonably give threatens health and puts patients throughout Canada at risk. In Ontario, the Resource Intensity Weights an indicator of acuity and case complexity of hospitalized patients has steadily increased since 1994 20 and nurses work correspondingly harder. 21 Nurses must also cope with under-staffing and excessive overtime due to the system-wide shortage. Older, experienced nurses find it particularly difficult to sustain the intensive workload because their clinical experience means mentoring and administration as well as caring for patients at the bedside. Additional work pressures, related to or made more stressful by high workloads include time pressures, contradictory demands, interruptions, the need for intense concentration, skill and knowledge deficits and insufficient or unavailable resources. Table 1: Major Nursing Worklife Issues (adapted from Kristensen, 1999) Principles Issues Demands fitting the resources of the person Degree of basic predictability Degree of social support Degree of meaning Degree of influence Balance between effort and reward Work pressures Job security; workplace safety; violence in the workplace Support by managers and colleagues; education and development Professional identity Control over practice; control over scheduling; nursing leadership Remuneration; recognition and rewards 4 Commitment and Care
5 Commitment and Care Research by O Brien-Pallas and colleagues indicates that heavy workloads contribute to job strain and suggests that shortterm increases in productivity lead to longterm health costs. 20 Nurses in most clinical units in Ontario particularly nurses in emergency and medical surgical units work at intensities that could harm their health. The study noted an almost perfect correlation between the hours of overtime worked and sick time. 20 Heavy workloads may also explain why full-time nurses have higher rates of absenteeism than part-time nurses. 21 High percentages of nurses in Canada, the United States, the United Kingdom and Sweden have reported work pressures severe enough to affect patient care 22,23, 24, 25 and there is evidence that lower nurse-to-patient ratios lead to complications and poorer patient outcomes. 25,26,27 Conversely, higher staffing levels are linked to better outcomes. 27,28 A problem for human-resource managers is knowing what a reasonable workload for nurses is. 29,30 Current workload-measurement systems focus on basic nursing tasks, ignoring the medical and nursing complexity of patients, the characteristics of nurses providing care and the caregiving environment 30 and measure only part of the actual work done. 29 As a result, nursing effort and expertise are not adequately recognized, measured, or compensated. Solutions: Often staff numbers still reflect funding contingencies rather than staff or patient needs, but many organizations are reevaluating staffing practices. Managers must ensure a fit between nurses needs and the demands of the job. Many stakeholders suggest that more nurses should be hired, new full-time positions created by reallocating money currently assigned to casual positions and permanent float nurses hired. Creating senior nursing positions such as clinical coordinators would allow bedside nurses to concentrate on patient care. Hiring additional clerical staff and nursing and personal care attendants would also relieve pressure. Research is proceeding on nursing workload and criteria for staff-to-patient ratios, but empirically based approaches incorporating a theoretical framework and the many factors that influence nursing workload are still in the development stage. 31 Efforts to create better systems must be intensified to enable human-resource planners to Better communication and closer relations among team members would help to reduce job stress. make better staffing decisions. Better communication and closer relations among team members would help to reduce job stress. Team meetings, which often lapsed during restructuring, need to be re-established. As well, organizing child and elder care and 24- hour cafeteria services, providing staff lounges, giving nurses input into the design of their workspaces, and ensuring that breaks can be taken would help to mitigate some of the pressures of nurses work. Ensuring adequate supplies and appropriate technology for nurses in all settings would also be helpful. Degree of basic predictability A high level of basic predictability is an important requirement for a healthy workplace. Three sources of unpredictability for nurses are job security, risk of injury, and
workplace violence. Job security Issues: During the 1990s, many industries attempted to improve efficiency by doing more with less, a strategy that often led to cycles of downsizing and internal reorganization. Studies across occupational groups suggest that employees with the least-secure jobs suffer the most anxiety, depression, burnout, poor health and sleep, and higher rates of absenteeism. 32 Studies in Qu bec confirm the link between health and job insecurity for nurses 33 and in Ontario between job insecurity and both job dissatisfaction and lower commitment to their organizations. 34,35,36,37 The current nursing shortage has increased job security, but the climate of distrust generated by downsizing remains. Solutions: Re-establishing trust between management and front-line staff requires good communications. 38,39 Successful communication includes not only what is communicated but how it is communicated. Research on communication in healthcare organizations is limited but suggests that frequent informal communication among hierarchical levels is more effective than formal meetings. 40 Workplace safety Issues: Healthcare workers suffer more musculoskeletal injuries than other occupational groups, losing a total of 169,579 days to strain-related disability in 1997 in British Columbia alone. 41 Nurses, in particular, experience high rates of strains and sprains. 42,43 According to Statistics Canada, their job-related injuries are more costly than those of high risk occupations such as fire fighters, police or transportation workers. 12 Several studies found a relationship between staff density, work overload, stress and musculoskeletal injuries in nursing workplaces 44 and there is evidence that job strain a combination of high job demands and low decision latitude increases the rate of injury. A longitudinal study of 4,000 healthcare workers in British Columbia showed that job strain increased the risk of musculoskeletal injury and claims. 45 Similarly, a cross-sectional study of Swedish nurses found job strain associated with a two-fold increased risk of low-back pain. 46 Many nurses injure their backs when units are short-staffed and they must lift patients by themselves. 47 A prospective study of overexertion back injuries by 24,500 Swedish nurses over one year revealed that most incidents occurred during patient transfer, often when nurses were working alone. 48 A retrospective review of 221 sharp injuries occurring over a year in a large tertiary-care hospital in British Columbia suggested that 59 percent of moderate and high-risk injuries could have been prevented. 49 Education and appropriate procedures decrease the risk of injury but organizational factors also make a difference. 50 In one study, higher needlestick injury rates were associated with temporary nurse staffing, whereas lower injury rates characterized magnet hospitals o rganizations with reputations as excellent nursing workplaces where staffing was stable. 51 Other work-related problems, such as latex allergies, are also costly. Solutions: It can be inferred that strategies to decrease workload may decrease injury rates. Many workplace safety programs exist but the literature indicates that they may be unsuccessful where work pressures and staff instability encourage dangerous work practices. Evidence from the field suggests that poor workplace maintenance, inadequate equipment and supply shortages increase nurses risk of injury and that equipment such as 6 Commitment and Care
7 Commitment and Care patient lifts could prevent injuries. Violence in the workplace Issues: Violence in the workplace increases the unpredictability of nurses work. The Canadian Centre for Occupational Health and Safety 52 defines A survey of selected hospitals in Alberta and British Columbia reported that many nurses had experienced violence in the previous five shifts. workplace violence as any act in which a person is abused, threatened, intimidated or assaulted in his or her employment. Perpetrators may be nurses, other professionals, or patients and their families. It is difficult to estimate the prevalence of workplace violence because it is not consistently defined and is probably under-reported. 53 A survey of selected hospitals in Alberta and British Columbia reported that many nurses had experienced violence in the previous five shifts. 54 Thirtyeight percent had experienced hurtful remarks or attitudes, humiliation in front of the work team, or coercion. A considerable number had received verbal or written threats or had been physically assaulted. In Alberta, patients initiated most assaults but about a quarter of the verbal abuse came from physicians or nursing colleagues. Risks to nurses in hospitals and community settings are increasing, perhaps an aspect of an increasingly violent society; but understaffing may also be a factor because longer waiting times in emergency departments are associated with attacks on staff. 55 Solutions: Many hospitals are attempting to create aggression-free environments and have increased security in key areas. Focus group participants called for firm policies to deal with abusive behaviour, more support for staff dealing with patients and families, and the use of volunteers to provide personal contact for patients frustrated by delays. They argued that safe parking spots, risk-assessment tools, lifeline buzzers for nurses in the community or in dangerous settings, counselling services, and procedures for reporting and quickly following up abusive behaviour by nurses and other professionals would be effective strategies for reducing workplace violence. Degree of social support In the last decade, there have been significant changes in the emotional and cognitive support that nurses receive in the workplace. Society has moved away from the traditional workplace and the psychological contract in which the employer offered job security and support in exchange for work well done 38 to a world where employers may offer part-time or casual work and employees have several jobs. Social support in the workplace comes from managers, supervisors and colleagues and cognitive support from mentors and from organizational policies that help with professional development and careers. Support by managers and colleagues Issues: A Canadian study of nurses during cutbacks showed that support from supervisors and co-workers reduced job strain. Nurses with supportive supervisors remained committed and those who felt supported by the personnel department felt less insecure about their jobs, more satisfied with workload and
career opportunities and had higher satisfaction overall. Good relationships with co- 38, 39 workers and supervisors may also reduce job turnover. 56 Published studies and evidence from the field suggest that nurses commitment to their organizations has decreased, at least partly out of a belief that employers no longer support them. After the dismissal of chief nurses and middle managers during restructuring, nurses received less emotional support and had no one to turn to for advice on patient or unitrelated problems. Redeployment of nursingteam members also reduced collaboration in patient care and relationships with other healthcare professionals deteriorated because everyone was experiencing pressure and had little time for the social interaction that builds strong teams. Solutions: During the last nursing shortage, magnet hospitals did not suffer from staff shortages. 40 Today, organizations seeking to be employers of choice need to offer a new type of psychological contract in which they offer excellent workplace conditions in return for high standards of work. Good team relations affect patients, 57 even reducing mortality, 58 and there is evidence that better patient outcomes occur when there is good collaboration between nurses and physicians. 28, 59 As well, focus group participants agreed that nurses needed middle managers to facilitate relations both inside and beyond the work group. Baumann and colleagues 60 suggest that professionals in multi-disciplinary teams should avoid conflict by concentrating on the patient s needs rather than their own professional roles. Education and professional development Issues: During restructuring, healthcare organizations decreased their level of support for professional development. The shift to program management meant that mentoring and evaluation of junior nurses became less common and resources for continuing education were cut. Today, staff shortages make attendance at educational courses difficult even when they are available. Solutions: Organizations can support nurses by backing their clinical decisions, offering educational and professional development, and providing career opportunities. Performance evaluation and mentoring in nursing teams provide opportunities for encouragement, validation, and goal-setting, while lack of supervision allows standards to fall. 35 A British Columbia government program 61 enables senior nurses to be relieved of 20 to 30 percent of patient care in return for mentoring new nurses. Organizations need to invest more in continuing education for nurses. It is essential for nurses to keep abreast of new knowledge and developments. As well, baccalaureate degrees are becoming the qualification for entry to practice and teachers with higher degrees are needed in schools of nursing. While there is no direct evidence that continuing education improves patient care, studies confirm that the higher the registered nurse skill mix the more effective the care. 62,63 As well, access to education is a strong message to nurses that the organization values them. Degree of meaning Nurses find meaning in their work when they are able to care for patients by performing in a way that conforms to the philosophy of care held by the nursing profession. Professional identity Issues: As members of regulated professions with standards established by professional organizations, nurses are supplied with 8 Commitment and Care
9 Commitment and Care scope of practice guidelines. However, nurses perceptions of the kinds of roles they should play are also acquired during their nursing education and in the workplace through interaction with colleagues and mentors. From these sources, nurses develop both professional and personal standards of care. While there is individual variation in how nurses see their roles, most nurses subscribe to a holistic philosophy of care and their work has most meaning when they are able to attend to all aspects of a patient s health. In the contemporary healthcare environment, the nursing model of caring often takes second place to a treatment-oriented medical model. 60 Due to their high workloads, nurses only have time for tasks related to patients immediate physical needs. As a result they often become discouraged and feel guilty when they neglect patients psycho-social and spiritual needs. 35 Solutions: More attention should be paid to understanding nurses philosophy of care and to recognizing its place and value in the healthcare system. Degree of influence There are three major issues for nurses relevant to increasing their influence in, and consequently their loyalty to, their place of work control over practice, control over scheduling, and nursing leadership. Control over practice Issues: Establishing a professional role is a prerequisite for establishing control over practice. New technologies and organizational change have led to confusion between the roles of registered nurses and registered practical nurses and the allocation of responsibilities varies even within institutions. This causes tension in the nursing team, making it less efficient. Control over practice the freedom to act independently to the full scope of their training is consistently related to job satisfaction 64 and there is evidence that providing greater decision-making latitude for nurses decreases turnover. 65 A recent study of a large, random sample of Ontario nurses found that workplace empowerment strongly predicted lower job strain and job satisfaction. 64 These findings have implications for mental and physical health as well. 66 When nurses have limited say in patient care, they feel their expertise is not valued, which in turn lowers their commitment to their employers. They believe that they should have input into all aspects of patient care within their scope of practice, including serving as patient advocates. Administrators often lack understanding of nurses roles and expertise. During restructuring, nurses were frequently shifted to jobs without regard for their specialist knowledge, 35, 67 and even now nursing qualifications and clinical knowledge are often not even specified in advertised positions. This is a waste of available expertise. 68 Solutions: While regulatory bodies supply general guidelines, registered nurses and licensed practical nurses also need to negotiate their work roles in their specific work environments. Nurses need to be included in job design for healthcare aides so that they can provide input on how the aides can be most useful. Greater understanding of the nursing role will help nurses engage in the meaningful work that will keep them committed to their jobs. Focus group participants strongly supported the need for nurses to have input into patient-care decisions related to their practice.
Helping nurses practice in ways which satisfy them has other benefits. A study by Weisman and Nathanson 69 reported that the job-satisfaction level of nursing staff was the strongest determinant of the aggregate satisfaction level of clients. Control over scheduling...most nurses subscribe to a holistic philosophy of care and their work has most meaning when they are able to attend to all aspects of a patient s health. Issues: Setting their own schedules would help nurses feel more in control. As the nursing shortage grows, the difficulty of replacing absent staff means that nurses are pressured to work inconvenient shifts and more mandatory overtime. Casual staff are in greater demand, which gives them more leverage to work their hours of choice, while full-time nurses, over whom managers have more control, get less choice over hours or shifts worked. Focus group participants said that some nurses use call display to screen calls to avoid working yet another unscheduled shift. The trend toward part-time and casual work may have led to disruption of nursing teams, increased orientation costs, decreased continuity of patient care and even dissuaded people from a nursing career. Yet many nurses still cannot satisfy their preference for full or part-time work. Those who work full-time but would prefer part-time hours are dissatisfied, 34 while younger nurses with educational loans to repay often emigrate if offered only parttime jobs. Solutions: Human-resource managers may need to reassess their strategies for recruiting nurses to accommodate individual preferences. Both the literature and field evidence suggest flexible scheduling gives nurses better control of their hours of work. Some employers have successfully implemented self-scheduling or innovative strategies that allow nurses to work full-time but with hours that suit their lifestyle. Employers can learn from the experiences of other organizations and work with unions to overcome problems that prevent nurses from working schedules that suit them. 31 Employers can also consolidate their workforces by differentiating those who work part-time (often because of family commitments) from casual workers, and offering the part-timers similar benefits and incentives to full-time staff. If the costs associated with overtime hours (usually time and a half) were redirected to full-time equivalent hours, savings might be realized. Nursing leadership Issues: Nurses find it difficult to play significant roles in policy-making or communicate effectively with decision makers because they are under-represented in institutional hierarchies. As a result, they have limited power to influence change or to act to make things better. Research literature and evidence from the field confirm that nurses limited participation in decision-making is inefficient and can be dangerous. For example, the report of the Manitoba Pediatric Cardiac Surgery Inquest into the deaths of 12 children noted that nurses were never treated as full and equal partners in the surgical team and that their serious and legitimate concerns were disregarded. 74 Nursing leadership was severely weakened when chief nurses, head nurses and unit managers were dismissed. The introduction of organizational designs such as program 10 Commitment and Care
management left nurses with very few opportunities for promotion and deprived them of disciplinary leadership. Balance Between Effort and Reward 11 Commitment and Care Studies show that good nursing leaders can increase group cohesion and ameliorate job stress 70 and there is evidence that leadership which supports and empowers nurses reduces turnover. 40,71,72 Wilson and Laschinger 73 found that nurses views on access to power and opportunity in their own jobs depended on their perceptions of their manager s powerfulness. Nurses in the restructured workplace are often supervised by non-nurses, which can mean that problems such as poor practice may go unreported or unheeded by managers who do not appreciate their significance. Solutions: Organizational influence is possible in a climate of respect, where workers are not treated as a detachable human resource. 75 Nurses need career ladders in both clinical and bureaucratic hierarchies. Head nurses and chief nursing officers are being reinstated in some hospitals. Innovations such as shared governance and nursing-practice committees that address nurses concerns about their practice environment and involve them in policy-making are proving beneficial in some institutions. Pressure is growing for the return of chief nursing officers and there is some support for the inclusion of nurses on boards of directors. In Quebec, legislation ensures that hospitals and healthcare centres have a director of nursing care who is a nurse and that every institution with five or more nurses has a council of nurses responsible to the board of directors. 76 Similar strategies should be considered in other provinces....money only becomes a major issue in the absence of other sources of satisfaction. Siegrist s Effort/Reward model 19 suggests that when workers see an imbalance between the efforts they put into their work and the rewards they receive, pathological emotional and physical reactions occur. Because people s feelings about their jobs differ, it is difficult to identify a balance between effort and reward. Rewards that have been offered to nurses include money, recognition, and opportunities for personal and/or professional growth. Remuneration Issues: Nursing literature supports a relation between nurses satisfaction with pay and their overall job satisfaction but suggests that money only becomes a major issue in the absence of other sources of satisfaction. 77 In some provinces, the system of bidding for contracts for community-care delivery has resulted in intense competition among providers and driven nurses wages far below what hospitals pay. Bidding also encourages short-term contracts that decrease job security. The result is a shift of personnel to the hospital sector. The transfer of public health to the municipal level has also led to lower wages and a reduction of public-health nursing services that will ultimately affect the public s health. 78 Solutions: As the emphasis on community care grows, it is increasingly important to ensure that community and long-term-care nurses receive pay equity. Recognition and rewards Issues: Nurses perception that they and their profession are not valued suggests a dis-
crepancy between effort and reward. Nursing pay scales have relatively few increments so there is little recognition for advanced clinical expertise. As well, advertisements for nurses to care for specific patient populations rarely specify specialist qualifications or experience, an oversight that leads to the under-use of nursing skills to the detriment of the organization and its patients. 68 Governments also fail to make use of nurses skills. In Ontario, despite a legal and regulatory framework passed in 1997 and research that supports their effectiveness, nurse practitioners have difficulty finding positions. While the Ministry of Training, Colleges and Universities funds their education for independent practice, the Ministry of Health and Long-Term Care will only pay them indirectly, through physicians except in the north and in isolated areas. Few find work in urban centres, even when there is a shortage of family doctors. 79 quality of worklife. Solutions: Strategies that would make nurses feel more valued and involved in their workplaces include pay bands reflecting levels of experience, adding increments to pay scales, encouraging more senior nurses to act as mentors and consultants and recognizing significant achievements by nurses. Finding a way for nurses to progress in their careers without abandoning direct patient care known as clinical laddering makes them feel rewarded while letting the organization maintain high standards of care. Ministries of health need to change their funding practices to allow nurse practitioners to practice independently as they have been trained to do. Focus-group participants agreed that nurses need safe, convenient workplaces, car allowances, long-term contracts and technology for communicating with colleagues. In hospitals and long-term-care facilities, improvements such as wellness programs, fitness classes, exercise equipment, and opportunities for socializing do much to improve nurses 12 Commitment and Care
How Can We Improve Nurses Well-Being? 13 Commitment and Care No one questions that there is a nursing shortage. Governments, nursing associations and individual organizations are all struggling to sustain patient care. To succeed, they will have to go beyond recruitment campaigns. Nursing today offers limited benefits and many challenges; if it s to remain a viable profession, its status must be enhanced and the welfare of nurses promoted. Nurses are important human capital and it is crucial to invest in their well-being because the welfare of patients ultimately depends on the excellence of their work. Many of the ideas suggested in focus groups and interviews have already been implemented somewhere in Canada, but competition among healthcare institutions often slows dissemination of new ideas. 80 The question is how to bring about the various changes cultural, structural, material and strategic that will enhance nursing welfare. Cultural and structural change Nursing fails to attract and retain recruits because it does not offer them sufficient stake in the healthcare industry. Recent graduates are increasingly unwilling to remain in a career that gives them little scope for career growth and in which they can feel vulnerable to factors beyond their control. The viability of the nursing profession and the well-being of nurses depends on a cultural change in the value placed on nurses and nursing and on making structural changes that allow nurses greater input into healthcare. The federal and provincial governments are inviting input on policy-making from nurses. 81 The joint federal, provincial and territorial Advisory Committee on Health Human Resources set out a pan-canadian strategy which included establishing a multi-stakeholder Canadian Nursing Advisory Committee. 82 In May 1999, the Office of Nursing Policy was established at Health Canada to influence the health of Canadians by optimizing the contribution of nursing knowledge and nursing practice 83 and to provide federal policy makers with nursing perspectives. Provincial governments are getting nurses involved in policy-making by establishing chief nurse or senior nursing advisory roles and committees. It is important to ensure that these initiatives are sustained after the current crisis has passed. Nursing today offers limited benefits and many challenges; if it s to remain a viable profession, its status must be enhanced and the welfare of nurses promoted. Less progress has been made in changing the culture of healthcare organizations. Boards need to broaden their agendas to include the effect of policy-making on workers, the workplace, and ultimately on patients, and to make their membership more inclusive. It is rare for nurses to have a voice at board level even though they are the largest group of workers and the major caregivers. Nurses need to be included at all levels in the structural hierarchy of healthcare organizations so that they can control their practice, work to ensure the funds and resources to support it and, most importantly,
give their insights into policy. Nurses have some leverage over employers in crises such as nursing shortages but as changes in the early 1990s showed, without established representation in organizational hierarchies, it is difficult to sustain advances after crises have passed. Nurses can use nursing-practice committees or shared governance to help them address issues related to patient care and scope-of-practice. Strategic and material change Strategic changes and the resources to make them feasible are needed to improve the welfare of nurses, maintain an adequate workforce and benefit patients. In recent years the healthcare system has been characterized by unpredictability, largely because of funding uncertainties. Stable funding will permit longterm planning and create a more effective, sustainable system. Because nurses lack influence in policy-making, decision makers in employing organizations often regard them as an expensive resource rather than professional colleagues. Governments can encourage investment in nursing welfare by allocating adequate funds for nursing, setting rules for employers on using this money and changing policies to ensure pay equity. improve efficiency, and worklife enhancements to reduce stress and ease the homework interface. Various ways of improving nurses wellbeing have been tried. A number of provincial nursing associations have introduced criteria for assessing the quality of practice settings, including the College of Nurses of Ontario s Practice Setting Consultation Program 84 and the Registered Nurses Association of British Columbia s Supporting Agencies, Supporting Nurses, 85 and are assisting nurses with improving their work environments. The American Nurses Credentialing Center uses the Magnet Hospitals Recognition Program to identify hospitals with good clinical practice environments, high retention rates, job satisfaction, nurse autonomy and good inter-professional relations. 86 Some Canadian organizations have expressed interest in participating in this program and others in designing their own magnet environments. 87 Employers and professional organizations must also be involved if nursing workplaces are to achieve positive change. Organizational policies directly and indirectly affect the amount and types of work nurses do, their responsibilities, and with whom they work. It is important that decision makers consider changes carefully and monitor them for unforeseen consequences. Changes must also be supported by appropriate allocation of money and resources. Nurses can be more productive and healthy in safe, ergonomically sound work environments, with access to the supplies, services and technology they need to 14 Commitment and Care